Priya Daniel

What Is the Potential Role of Transcutaneous Carbon Dioxide in Guiding Acute Noninvasive Ventilation

BACKGROUND: Transcutaneous carbon dioxide (PtcCO2) monitoring is rarely used in the acute hospital setting, where serial samples of arterial blood are instead taken to measure carbon dioxide tension (PaCO2). In this pilot observational study, we assessed the potential of PtcCO2 monitoring to calculate pH and guide management of acute noninvasive ventilation (NIV). METHODS: Ten subjects with acute hypercapnic respiratory failure were recruited. All had arterial lines placed to guide acute NIV. PtcCO2 was monitored for 12 h (TOSCA TCM4) and compared with PaCO2. Noninvasive transcutaneous pH was determined from PtcCO2 and calculated bicarbonate and then compared with true arterial pH. Agreements between PCO2 and pH methods were assessed using Bland-Altman analysis of limits of agreement and Pearson correlation coefficients. Hypothetical adjustments to acute NIV settings were based on transcutaneous data alone and evaluated in comparison with true management. Pain scores for each method were compared using the Wilcoxon signed-rank test. RESULTS: PCO2 time trends were concordant. Mean PCO2 bias was −2.33 (95% limits of agreement of −9.60 to 5.03) mm Hg, and r = 0.89 (P < .001). Mean pH bias was 0.012 (95% limits of agreement of −0.070 to 0.094), and r = 0.84 (P < .001). Hypothetical clinical decisions based on transcutaneous data alone matched true management on 85% of 34 occasions. Initiation of transcutaneous monitoring was less painful than the arterial equivalent (P = .008). CONCLUSIONS: This pilot study demonstrates that PtcCO2 monitoring provides a continuous and reliable trend and also allows pH prediction. This patient-friendly approach is a promising alternative to repeated arterial blood gas sampling in patients requiring NIV for acute hypercapnic respiratory failure.

Mortality reduction in adult community-acquired pneumonia in the UK (2009–2014): results from the British Thoracic Society audit programme

Community-acquired pneumonia (CAP) is a leading cause of death in the UK. In this analysis of 23 315 cases from the British Thoracic Society national CAP audit, an overall reduction in 30-day inpatient mortality over 6 years was observed—2014 compared with 2009 adjusted OR 0.86 (95% CI 0.68 to 1.08, p for trend 0.004). Significant increases in the proportions of patients who had (a) a chest X-ray and (b) the first antibiotic dose within 4 hours of admission were also observed (3.7% and 11.5% increases respectively). Further reductions in mortality may follow the 2016 National Institute for Health and Care Excellence Pneumonia Quality Standard.

Time to first antibiotic and mortality in adults hospitalised with community-acquired pneumonia: a matched-propensity analysis.

A matched-propensity analysis of national data from the British Thoracic Society community-acquired pneumonia audit was conducted (n=13 725). Overall, time to first antibiotic (TFA) was ≤4 h in 63%. Adjusted 30-day inpatient (IP) mortality was lower for adults with TFA ≤4 h compared with TFA >4 h (adjusted OR 0.84, 95% CI 0.74 to 0.94; p=0.003). Increasing TFA was associated with greater OR of 30-day IP mortality (p value for trend=0.001), but no TFA threshold was evident. Although we found an association between TFA and mortality, we cannot say whether this is causal or whether TFA might just be a quality measure for overall or other processes of care.

Development of an Extended-Specificity Multiplex Immunoassay for Detection of Streptococcus pneumoniae Serotype-Specific Antigen in Urine by Use of Human Monoclonal Antibodies

ABSTRACT Current pneumococcal vaccines cover the 10 to 23 most common serotypes of the 92 presently described. However, with the increased usage of pneumococcal-serotype-based vaccines, the risk of serotype replacement and an increase in disease caused by nonvaccine serotypes remains. Serotype surveillance of pneumococcal infections relies heavily on culture techniques, which are known to be insensitive, particularly in cases of noninvasive disease. Pneumococcal-serotype-specific urine assays offer an alternative method of serotyping for both invasive and noninvasive disease. However, the assays described previously cover mainly conjugate vaccine serotypes, give little information about circulating nonvaccine serotypes, and are currently available only in one or two specialist laboratories. Our laboratory has developed a Luminex-based extended-range antigen capture assay to detect pneumococcal-serotype-specific antigens in urine samples. The assay targets 24 distinct serotypes/serogroups plus the cell wall polysaccharide (CWP) and some cross-reactive serotypes. We report that the assay is capable of detecting all the targeted serotypes and the CWP at 0.1 ng/ml, while some serotypes are detected at concentrations as low as 0.3 pg/ml. The analytical serotype specificity was determined to be 98.4% using a panel of polysaccharide-negative urine specimens spiked with nonpneumococcal bacterial antigens. We also report clinical sensitivities of 96.2% and specificities of 89.9% established using a panel of urine specimens from patients diagnosed with community-acquired pneumonia or pneumococcal disease. This assay can be extended for testing other clinical samples and has the potential to greatly improve serotype-specific surveillance in the many cases of pneumococcal disease in which a culture is never obtained.

Adults miscoded and misdiagnosed as having pneumonia: results from the British Thoracic Society pneumonia audit

A key objective of the British Thoracic Society national community-acquired pneumonia (CAP) audit was to determine the clinical characteristics and outcomes of hospitalised adults given a primary discharge code of pneumonia but who did not fulfil accepted diagnostic criteria for pneumonia. Adults miscoded as having pneumonia (n=1251) were older compared with adults with CAP (n=6660) (median 80 vs 78 years, p<0.001) and had more comorbid disease, significantly fewer respiratory symptoms (fever, cough, dyspnoea, pleuritic pain), more constitutional symptoms (general deterioration, falls) and significantly lower 30-day inpatient mortality (14.3% vs 17.0%, adjusted OR 0.75, p=0.003).

Healthcare reconsultation in working-age adults following hospitalisation for community-acquired pneumonia.

ABSTRACT Community-acquired pneumonia (CAP) is associated with prolonged symptom persistence during recovery. However, the effect of the residual symptom load on healthcare utilisation is unknown. The aim of this study was to quantify healthcare reconsultation within 28 days of hospital discharge for an index episode of CAP, and explore reasons for these reconsultations. Adults of working age admitted to any of four hospitals in the UK, with a primary diagnosis of CAP, were prospectively studied. Of 108 patients, 71 (65.7%) reconsulted healthcare services within 28 days of discharge; of these, 90.1% consulted their GP. Men were less likely to reconsult than women (adjusted odds ratio [aOR] 0.34, 95% confidence interval 0.13–0.91, p=0.032). Persistence of respiratory symptoms accounted for the majority of these reconsultations. Healthcare utilisation is high in working-age adults after an episode of hospitalised CAP and, in most cases, is due to failure to resolve index symptoms.

Increased incidence of adult pneumococcal pneumonia during school holiday periods

Child contact is a recognised risk factor for adult pneumococcal disease. Peaks in invasive pneumococcal disease incidence observed during winter holidays may be related to changes in social dynamics. This analysis was conducted to examine adult pneumococcal community-acquired pneumonia (CAP) incidence during school holiday periods. Between September 2008 and 2013, consecutive adults admitted to hospitals covering the Greater Nottingham area with a diagnosis of CAP were studied. Pneumococcal pneumonia was detected using culture and antigen detection methods. Of 2221 adults studied, 575 (25.9%) were admitted during school holidays and 643 (29.0%) had pneumococcal CAP. CAP of pneumococcal aetiology was significantly more likely in adults admitted during school holidays compared to term time (35.3% versus 26.7%; adjusted OR 1.38, 95% CI 1.11–1.72, p=0.004). Over the 5-year period, the age-adjusted incidence of hospitalised pneumococcal CAP was higher during school holidays compared to term time (incident rate ratio 1.35, 95% CI 1.14–1.60, p<0.001); there was no difference in rates of all-cause CAP or non-pneumococcal CAP. Reported child contact was higher in individuals with pneumococcal CAP admitted during school holidays compared to term time (42.0% versus 33.7%, OR 1.43, 95% CI 1.00–2.03, p=0.046). Further study of transmission dynamics in relation to these findings and to identify appropriate intervention strategies is warranted. School holiday periods are associated with an increased incidence of adult pneumococcal community-acquired pneumonia http://ow.ly/JiAb3089Gii